Thursday, January 30, 2014

I've talked before about the role of self-blame in maintaining depression. As I've read more on this topic I discvoered that self-blame is not always associated with depression. (I guess I don't really see those people who blame themselves but aren't depressed. They don't tend to need therapy). Based on personal experience, it seems like self-blame often provides people with a greater sense of control. If I did something wrong that caused something bad to happen then all I have to do to keep it from happening again in the future is to change my own behavior. For many of my patients, gaining this sense of control decreases anxiety but also causes a lot of guilt which, over time, leads to depression.

According to the research literature, however, this type of self-blame should not lead to depression. Peterson, Schwartz, and Seligman explain that attributing a negative event to one's own behavior increases perceived controllability (as I said before) and creates the sense that one's bad behavior was situation specific. (In other words, a person sees his behavior in a given situation as a one time thing. He doesn't see it as representative of a broader pattern of bad behavior or as a reflection of who he is as a person). Peterson et al. call this phenomenon "behavioral self blame" and describe it as an "attributional defense mechanism...[that is] inconsistent with depression."

So what gives? Why do I see so many depressed patients who blame their bad behavior for causing significant negative events? According to research, this sort of self-blame is a defense mechanism and should protect them from depression. Why does this not seem to be happening?

I don't have a definitive answer but I do have some ideas...

One thing that stands out to me is how many of my self-blaming patients seem unable to forgive themselves for making mistakes. Theoretically, attributing a negative event to their own behavior should boost their sense of control, leading to increased hopefulness about their ability to prevent similar events from taking place in the future. And yet, I don't often see hopefulness. Instead I see a tendency to dwell on perceived mistakes, which creates an overwhelming sense of guilt and self-doubt. It's difficult to feel hopeful about the future when you're busy condemning yourself for mistakes you made in the past. Part of "behavioral self blame" is "admitting I did something wrong." For some, making a mistake is simply unacceptable. In such cases, "behavioral self-blame" equates to perpertual self-condemnation; this inevitably leads to depression.

Or perhaps certain kinds of negative events are simply so terrible that normal rules don't apply. The negative events experienced by the majority of my patients fall into one of two categories: 1. Combat-related incidents in which one or more people were seriously injured and/or killed and 2. Sexual assault. Rape and violent death are more extreme than most other negative life events. Perhaps the reactions people have to these experiences are therefore more complex.

Another possiblity for some is their inability to identify what exactly they did wrong. That is, they have the general sense that they did something to cause a negative event but despite replaying the event in their minds again and again they are unable to identify a specific behavior that would explain what happened. They feel compelled to continue replaying the event in their minds in an effort to figure out exactly what they did wrong. I imagine the people who do this are people who have a pre-existing tendency to blame themselves when things go wrong; the drive to blame oneself in the absence of any evidence seems to suggest this.

Wednesday, January 22, 2014

It's easy to understand why we tend to avoid certain situations, activities, people, or tasks that stress us out, make us uncomfortable, or otherwise generate negative emotions. Nobody wants to feel bad, especially if there is some way to avoid it. Thus, if there is a particular situation that creates anxiety we will most likely avoid that situation whenever possible. It makes sense. There's no reason to deliberately cause ourselves suffering.

Similarly, we are sometimes faced with problems that create distress whenever we think about them. To avoid distress we simply avoid thinking about the problem. Of course we are typically unable to do this indefinitely, but we can always put things off until the last possible moment.

Avoiding things that cause us discomfort can be an effective strategy. If there is a certain person who always manages to get under our skin it is best to deal with said person as little as possible. If we are under a lot of stress and feeling overwhelmed, waiting until later to deal with certain problems could be the best way to preserve our emotional and psychological well being. We have to prioritize. If certain places make us uncomfortable and we don't have to go there then avoiding these places is completely logical. If talking about certain topics upsets us and there is no compelling reason to do so then it makes perfect sense to avoid conversations about said topics. If there are certain memories that are unpleasant to recall it can be beneficial not to recall them.

There are also times when avoidance is a very ineffective strategy. A coping mechanism is ineffective when it creates more problems than it solves. Avoidance has the potential to become this kind of strategy. Because avoidance is so effective at alleviating distress we can inadvertantly begin to rely too heavily on it as a coping mechanism. Anything that alleviates distress is inherently reinforcing. We feel distress, we avoid, the distress is gone. We feel better. We avoid more.

So when is avoidance detrimental? What follows are a few examples. This list is by no means exhaustive.

*When avoiding discomfort or distress becomes the primary factor you consider when deciding whether or not to do something. (Avoiding distress becomes your primary motivation; everything else takes a back seat).
*When the list of things you won't do because they cause distress grows so long that the list of things you will do is actually shorter. (The end result is that you spend most of your time at home and only leave when there's something you absolutely have to do).
*When you put off dealing with a problem or conflict for so long that you end up simply not dealing with it at all. (The problem doesn't go away, of course. It probably gets worse while you are busy not dealing with it).
*When you avoid doing things you need to do or dealing with things you need to deal with, despite significant negative consequences for doing so.
*When avoiding starts to cause conflict in significant interpersonal relationships.

Tuesday, January 14, 2014

A few weeks ago my husband and I had an argument. Things got kind of ugly and both of us ended up saying some not very nice things. After taking a few hours to regroup, we sat down to talk about what happened. I've mentioned before that my husband has a tendency to blame me when there's conflict in our relationship. In this particular instance, I'd clearly said and done some things that were hurtful. I was angry over what I felt were legitimate grievances but that didn't make my behavior okay. (Unfortunately, this was a conclusion I reached only in hindsight).

So when my husband sat down to talk things out the first thing I did was apologize. I admitted that my actions were inexcusable. My husband immediately agreed. He then proceeded to list a number of grievances he had with me. He concluded by asserting that anything he said or did that was upsetting to me was simply a natural reaction to having to deal with my bad behavior. He went on to say that if I would stop being so difficult to deal with then everything would be fine and we would get along perfectly.

I cannot completely capture how it feels to try to resolve a conflict with someone I love, to humble myself enough to admit I was wrong and to apologize for it, only to be told that I am the root of the problem. The most immediate emotion is anger. It feels like a slap in the face. I become defensive, like I have to justify myself or somehow prove my intentions are good. I feel frustrated. Sometimes I feel hopeless. "What's the point of trying to fix things?" I ask myself. "We never solve anything. He just ends up blaming me. Nothing changes." On several occasions I have ended the conversation at this point. I get pissed off and walk away. It doesn't solve anything but sometimes walking away seems like the only good option.

In this particular instance, however, walking away would have made things worse. So I told him it wasn't fair for him to place all the blame on me. "So you're saying that every argument is always both people's fault?" my husband asked.

I actually had to stop and think about this for a minute. In any given argument, are both parties at fault? Is this a rule that applies in all cases? Or are there arguments where one person is clearly to blame?

"Yes," I finally decided. "Because a disagreement doesn't have to turn into an argument," I explained. "And it always takes two people to argue. If one person refuses to engage then you can't have an argument," I added. I went on to qualify my statement. "I don't think both people are always equally to blame," I said. "There are times when one person clearly initiates an argument. The initiator would probably bear more responsibility in that case. But still, it takes two people to argue. If someone tries to start an argument and the other person won't take the bait then there's no argument. It's just one person acting like an asshole."

It is a tricky question though. I think most of us are inclinced to blame the other party when we get into any sort of conflict. This isn't always a bad thing. People are motivated to fight for something when they believe in the rightness of their cause.

It's different when the conflict is with someone you love. The best approach is probably just to agree to disagree, whenever possible. When this isn't possible compromise is the next best option. Of course this means that neither party gets everything they want and that both parties have to give something up. People are not always willing to do this.

I also think there is something to be said for acceptance. For example, I'm (begrudgingly) learning to accept that my husband is not going to actively participate in keeping our house neat and clean, no matter how often I ask him to help with these tasks. And he is (slowly) learning to accept that I become irritable when I'm stressed out and that unfortunately, I get stressed out pretty easily. Our tendency has been to get upset about these things again and again, to demand that the other change, and then to feel frustrated and disappointed when this doesn't happen. For me, it is extremely difficult to accept that my husband won't do something I think he should do. It makes me angry but not as much as it used to. I try to recognize the other ways he contributes to our lives. This is a work in progress.

Tuesday, January 7, 2014

I mentioned before that I was recently tasked to lead a therapy group focused on sexual assault, trauma, and depression. I did some background research to prepare. One thing that stood out to me is how frequently shame was mentioned as a factor contributing to depression. I mentioned this during the first group session. It seemed to resonate strongly with the group members. As they shared their experiences I spontaneously found myself talking about the "power of shame." I hadn't intended to go this route but it felt right. It ended up being a very powerful discussion.

In the ensuing days my thoughts repeatedly turned to the concept of shame. It's not something I've ever spent a lot of time talking about with patients, although it does come up in sessions. There are, however, certain treatment approaches to which the concept of shame is integral. John Bradshaw (http://www.johnbradshaw.com/) is probably the shame guru, if there is such a thing. His book, "Healing the Shame that Binds You," is a New York Times best seller. In it, Bradshaw points to "toxic shame" as the underlying cause of compulsions, addiction, co-dependencies, and the drive to super-achieve or underachieve."

Shame and guilt are often used interchangeably, which can sometimes cause confusion. For my purposes, I've decided to distinguish guilt and shame as follows:

*Guilt is a bad feeling caused by the fact of having committed a specific offense.

*Shame focuses on the entire self. It is a painful feeling arising from the judgment of oneself as dishonorable, disgraceful, disgusting, etc.

Thus, guilt is concerned with something specific a person has done. The focus of shame is on the self as a whole.

Like most human emotions, shame can be healthy in small doses. Shame can compel us to eliminate bad behavior and motivate us to act in ways consistent with our values. Healthy shame fuels personal growth and so helps us to become better people.

Too much shame is emotionally and psychologically toxic. (Bradshaw talks extensively about this in his book). There is significant overlap between the consequences of toxic shame and the symptoms of major depression. Here are some of the ways toxic shame manifests itself:

*Causes you to feel exposed and vulnerable, creating a sense that "everyone knows" how disgusting you are. This leads to a desire to hide, withdrawal, or otherwise escape from public view.

*Generates negative judgments about the self, which is seens as inferior, flawed, damaged, disgusting, worthless, etc.

*Creates a tendency to blame yourself when something goes wrong.

*Leads to a sense that you have a very limited amount of power to control what happens in your life. This eventually leads to feelings of hopelessness and helplessness.

*Can create social anxiety due to fears that others will judge you as negatively as you judge yourself.

Essentially, chronic shame leads to self-loathing; self-loathing leads to depression. I have come to believe that chronic, pervasive shame inevitably leads to depression. After all, how could a person hate himself and not become depressed over time?

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About Me

I'm a Licensed Clinicial Social Worker (i.e., a "sit on my couch and tell me your problems" therapist). I'm also a woman just like any other woman, with the same wants, needs, problems, thoughts, feelings, etc. Being a therapist gives me a unique perspective though -- I'm more self-aware than your average person and I understand why I do almost everything I do. (If I don't know why I usually set off on yet another journey to better understand myself). The title of my blog is "This is Me" but my hope is that it's not just about me -- it's about you too. I hope that you will find a little of yourself in my words and that in seeking to better understand myself others will have the opportunity to better understand themselves as well.